1712 Magnavox Way P.O. Box 2338 Fort Wayne, Indiana 46801-2338 MOTORSPORT (800) 348-1839 Fax (260) 459-5102 www.kandkinsurance.com DISABILITY INCOME California License #0334819 APPLICATION

APPLICANT INFORMATION Named of Insured (as it will appear on policy): Mailing Address: City: State: Zip: Phone: Fax: Website: Contact Person: Email: Who would be the beneficiary under the policy? Has any insurer ever declined to accept or renew, cancelled or accepted only at special terms any life, accident or illness insurance in respect of the person to be insured? q Yes q No Has the insured previously purchased this type of insurance in the last 3 years? q Yes q No

Effective Date Expiration Date Insurer Premium

Has the Insured had any claims incurred in the last 3 years? q Yes q No

If answered yes above please complete the following: Date Total Paid Track Details of Loss

Date of Birth: Height: Weight: Occupation: Team:

PROPOSER / AGENT / BROKER INFORMATION Name of Proposer (if someone other than insured is completing this): Name of Agency / Brokerage (if applicable): Mailing Address: City: State: Zip: Phone: Fax: Website: Contact Person: Email:

COVERAGE BENEFIT LIMITS A - Death by Accident Limit: B - Permanent Total Disablement due to Accident Limit: C - Accident Temporary Total Disablement Limit:  (Weekly benefit, in excess of the first 14 days) Elimination Period for B & C above Weeks:

D - Permanent Total Disablement due to Illness Limit: E - Illness Temporary Total Disablement Limit: (Weekly benefit, in excess of the first 14 days) Elimination Period for D & E above Weeks: F - Medical and Repatriation Expenses Limit:

Is this for 24/7 coverage not just limited to racing activities? q Yes q No

1916 9/15 Primary Sanctioning Bodies holding Covered Events: q FIA q IMSA q INDYCAR q NASCAR q SCCA q Other: Name of Championship: Are you driving a full season in this Championship: If competing in races held by other Sanctioning Bodies please provide a detailed schedule. What is your gross contracted salary, exclusive of bonuses this year? (Underwriters may ask for justification of this amount)

APPLICANT HISTORY PLEASE ANSWER ALL QUESTIONS FULLY AND TICK RELEVANT BOXES. IF THERE IS INSUFFICIENT SPACE TO ANSWER QUESTIONS FULLY IN THE SPACE PROVIDED PLEASE USE A SEPARATE SHEET OF PAPER WHICH MUST BE SIGNED AND DATED Are you currently in good health (free from injury and/or illness) and have you been so for the last 3 years? q Yes q No If ‘no’ please supply full details and complete the details:

Please advise the number of race activities you have missed and/or the amount of time you were disabled (due to injury or illness) for each of the last 3 seasons/years. If you have not had any injuries/illnesses please complete by writing Nil as applicable) Season / Year Missed Events / Time Injury / Illness

Have you ever had any Drivers License revoked, suspended or restricted? q Yes q No If ‘yes’ please supply full details including dates:

Have you attended a doctor or hospital due to any ailment or serious illness during the last 3 years? q Yes q No If ‘yes’ please supply full details including dates:

Have you had any operations or been involved in any form of accident? q Yes q No If ‘yes’ please supply full details including dates:

Have you had any X-Rays, CAT Scans or MRI Scans within the last 3 years? q Yes q No If ‘yes’ please supply full details including dates:

Have you taken any prescribed medicine, including courses of cortisone, pain reducing or anti-inflammatory medication during the last 3 years? q Yes q No If ‘yes’ please supply full details including dates:

OTHER ACTIVITIES Do you participate in any of the following? Winter Sports (Skiing, Snowboarding, Snowmobiling, Skating, etc.)? q Yes q No Skin Diving involving the use of breathing apparatus? q Yes q No Rock Climbing or Mountaineering normally involving the use of ropes or guides? q Yes q No Potholing (Cave Exploration)? q Yes q No Parachuting? q Yes q No Horse-riding? q Yes q No Flying (other than as a passenger in a commercial aircraft)? q Yes q No Riding motorcycles or motor scooters? If ‘yes’ please state engine size CC (Cubic Centimeters) q Yes q No Football and/or Rugby? q Yes q No Any other occupation, sport, pastime or activity which is likely to involve extra risk of accident? q Yes q No If the answer is ‘yes’ to any of the above questions, please supply full details:

1916 9/15 DECLARATION

To the best of my/our knowledge and belief, and having diligently made all necessary inquiries the information provided in connection with this proposal, whether in my/our own hand or not, is true and I/we have not withheld any material facts.

I/We understand that non-disclosure or misrepresentation of a *material fact will entitle Underwriters to void the Insurance.

NOTE: * A material fact is one likely to influence acceptance or assessment of this Proposal by the Underwriters: if you are in any doubt as to whether a fact is material or not, you must disclose it.

I/we understand that the Underwriters will determine the terms and conditions upon the information provided in connection with this proposal; and I/we further understand that the signing of this proposal does not bind me/us to complete or Underwriters to accept the insurance. Should a contract of insurance be concluded, this Proposal and any supporting information shall be incorporated into and form the basis of the contract.

I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information con- tained in the application and all other information being submitted. I hereby warrant, represent, and confirm that, to the best of my knowledge, all information provided is complete, true and correct.

Applicant’s Signature Producer’s Signature (if applicable)

Applicant’s Name (print) Producer’s Name (print)

Date (MM/DD/YY) Date (MM/DD/YY)

1916 9/15